title: Surgical skill and complication rates after bariatric surgery.
abstract: BACKGROUND
  Clinical outcomes after many complex surgical procedures vary widely across hospitals and surgeons. Although it has been assumed that the proficiency of the operating surgeon is an important factor underlying such variation, empirical data are lacking on the relationships between technical skill and postoperative outcomes.
  
  
  METHODS
  We conducted a study involving 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass. Each videotape was rated in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. We then assessed relationships between these skill ratings and risk-adjusted complication rates, using data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients.
  
  
  RESULTS
  Mean summary ratings of technical skill ranged from 2.6 to 4.8 across the 20 surgeons. The bottom quartile of surgical skill, as compared with the top quartile, was associated with higher complication rates (14.5% vs. 5.2%, P<0.001) and higher mortality (0.26% vs. 0.05%, P=0.01). The lowest quartile of skill was also associated with longer operations (137 minutes vs. 98 minutes, P<0.001) and higher rates of reoperation (3.4% vs. 1.6%, P=0.01) and readmission (6.3% vs. 2.7%) (P<0.001).
  
  
  CONCLUSIONS
  The technical skill of practicing bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department. Although these findings are preliminary, they suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon's proficiency.
authors.affiliation: Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA. jbirkmey@umich.edu
authors.forename: John D
authors.initials: JD
authors.lastname: Birkmeyer
authors.forename: Jonathan F
authors.initials: JF
authors.lastname: Finks
authors.forename: Amanda
authors.initials: A
authors.lastname: O'Reilly
authors.forename: Mary
authors.initials: M
authors.lastname: Oerline
authors.forename: Arthur M
authors.initials: AM
authors.lastname: Carlin
authors.forename: Andre R
authors.initials: AR
authors.lastname: Nunn
authors.forename: Justin
authors.initials: J
authors.lastname: Dimick
authors.forename: Mousumi
authors.initials: M
authors.lastname: Banerjee
authors.forename: Nancy J O
authors.initials: NJ
authors.lastname: Birkmeyer
mesh_terms: D000328:Adult; D050110:Bariatric Surgery; D002983:Clinical Competence / Q000592:standards; D005260:Female; D013502:General Surgery / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D020379:Risk Adjustment